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Orozco-Sebá BE, Viasus D, Meléndez E, Fuentes J, Tovar J, Amado EA, Loaiza D. Intrahepatic cholestasis due to Treponema pallidum in an immunocompetent patient. BIOMEDICA : REVISTA DEL INSTITUTO NACIONAL DE SALUD 2023; 43:164-170. [PMID: 37433168 PMCID: PMC10513144 DOI: 10.7705/biomedica.6630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 05/11/2023] [Indexed: 07/13/2023]
Abstract
Hepatitis due to Treponema pallidum is a rare entity and its diagnosis represents a clinical challenge. Treponema pallidum should be considered as a presumptive etiology in all patients with acute liver disease, when other frequent causes have been ruled out. We present the case of a young, immunocompetent patient with elevated values in his liver tests, a cholestatic pattern, and maculopapular lesions on his palms and soles. Given his clinical picture, diagnostic tests, and response to the antimicrobial therapy, a diagnosis of cholestasis due to secondary syphilis has been established. It is important to include secondary syphilis within the possible causes of acute liver disease.
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Affiliation(s)
- Beatriz E Orozco-Sebá
- Programa de Dermatología, División de Ciencias de la Salud, Facultad de Medicina, Universidad del Norte, Barranquilla, Colombia.
| | - Diego Viasus
- División de Ciencias de la Salud, Facultad de Medicina, Hospital Universidad del Norte de Barranquilla, Universidad del Norte, Barranquilla, Colombi.
| | - Esperanza Meléndez
- Programa de Dermatología, División de Ciencias de la Salud, Facultad de Medicina, Universidad del Norte, Barranquilla, Colombia.
| | - Jairo Fuentes
- Programa de Dermatología, División de Ciencias de la Salud, Facultad de Medicina, Universidad del Norte, Barranquilla, Colombia.
| | - José Tovar
- Programa de Dermatología, División de Ciencias de la Salud, Facultad de Medicina, Universidad del Norte, Barranquilla, Colombia.
| | - Elkin A Amado
- División de Ciencias de la Salud, Facultad de Medicina, Universidad del Norte, Barranquilla, Colombia.
| | - Daniela Loaiza
- División de Ciencias de la Salud, Facultad de Medicina, Universidad del Norte, Barranquilla, Colombia.
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Malvar G, Cardona D, Pezhouh MK, Adeyi OA, Chatterjee D, Deisch JK, Lamps LW, Misdraji J, Stueck AE, Voltaggio L, Gonzalez RS. Hepatic Secondary Syphilis Can Cause a Variety of Histologic Patterns and May Be Negative for Treponeme Immunohistochemistry. Am J Surg Pathol 2022; 46:567-575. [PMID: 34864775 DOI: 10.1097/pas.0000000000001848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The rate of syphilis in the United States has been increasing steadily in the past decade, but it remains an uncommon diagnosis in tissue biopsies. Most of the pathology literature on hepatic syphilis consists of older series or case reports. This study aimed to systematically characterize the histologic spectrum of hepatic syphilis in a contemporary cohort. Clinicopathologic features of 14 hepatic syphilis cases between 2012 and 2018 were analyzed to characterize the broad spectrum of histologic changes. Thirteen patients were men (age range: 19 to 59 y); 6 had known human immunodeficiency virus, 7 were men known to have sex with men, and no patient had known prior syphilis. Hepatic syphilis was the primary clinical suspicion in only 1 patient. Common symptoms included jaundice, rash, and abdominal pain. Thirteen had elevated transaminases, and 12 had elevated alkaline phosphatase. Pathologic changes were grouped into 5 histologic patterns: biliary-pattern injury (n=5), acute hepatitis (n=4), autoimmune hepatitis-like (n=1), fibroinflammatory mass-forming lesion (n=2), and no particular pattern (n=2). Nearly all showed portal and lobular lymphocytes and plasma cells; 12 had prominent histiocytes/Kupffer cells, 9 had ductular reaction, and 7 had duct inflammation. Occasional focal findings included dropout (n=7), phlebitis (n=7), and loose granulomata (n=5). Treponeme immunohistochemistry was positive in 10 and negative in 4, though treatment was given before biopsy in 3 of those 4. Thirteen patients had rapid plasma reagin testing either before or after biopsy, with 1:64 or higher titer. All patients who received treatment recovered. Hepatic syphilis is rare but likely underrecognized. It exhibits a variety of histologic appearances and therefore should be considered in several hepatic differential diagnoses, especially in men who have sex with men. Kupffer cells, granulomata, and phlebitis may suggest the diagnosis regardless of predominant histologic pattern. Negative treponeme immunohistochemical staining does not exclude the diagnosis, including in untreated patients.
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Affiliation(s)
- Grace Malvar
- Beth Israel Deaconess Medical Center
- Department of Pathology, Harvard Medical School
| | - Diana Cardona
- Department of Pathology, Duke University Medical Center, Raleigh, NC
| | - Maryam K Pezhouh
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Oyedele A Adeyi
- Department of Pathology, Toronto General Hospital, Toronto, ON
| | - Deyali Chatterjee
- Department of Pathology & Immunology, Washington University, St. Louis, MO
| | - Jeremy K Deisch
- Department of Pathology and Human Anatomy, Loma Linda University Medical Center, Loma Linda, CA
| | - Laura W Lamps
- Department of Pathology, University of Michigan Hospitals, Ann Arbor, MI
| | - Joseph Misdraji
- Department of Pathology, Harvard Medical School
- Department of Pathology, Massachusetts General Hospital, Boston, MA
| | - Ashley E Stueck
- Department of Pathology, Dalhousie University, Halifax, NS, Canada
| | | | - Raul S Gonzalez
- Beth Israel Deaconess Medical Center
- Department of Pathology, Harvard Medical School
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Al Dallal HA, Narayanan S, Alley HF, Eiswerth MJ, Arnold FW, Martin BA, Shandiz AE. Case Report: Syphilitic Hepatitis-A Rare and Underrecognized Etiology of Liver Disease With Potential for Misdiagnosis. Front Med (Lausanne) 2021; 8:789250. [PMID: 34912834 PMCID: PMC8666961 DOI: 10.3389/fmed.2021.789250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 11/09/2021] [Indexed: 11/13/2022] Open
Abstract
Syphilitic hepatitis (SH) in adults is a rare condition that can be easily misdiagnosed. Clinical and histopathologic manifestations of SH can mimic other infectious and non-infectious conditions, and the diagnosis should be considered in all at-risk patients with abnormal liver function tests. We present an unusual case of SH presenting with seizures and multiple liver lesions. This case report, in line with other newly published reports, promotes awareness of SH as a rare manifestation of treponemal infection and highlights the importance of including SH in the differential diagnosis for patients at risk for sexually transmitted infections and presenting with liver enzyme abnormalities. From a hospital quality control and socioeconomic perspective, our case adds to the growing body of evidence that demonstrates an increasing incidence of patients suffering from venereal diseases and injection drug use disorders, and the burden these conditions place on the healthcare system. Recognition of the clinicopathologic features of SH is required to prevent missed diagnosis and to foster systematic crosstalk between healthcare staff and public health personnel managing this problem.
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Affiliation(s)
- Hiba A Al Dallal
- Department of Pathology and Laboratory Medicine, University of Louisville, Louisville, KY, United States
| | - Siddharth Narayanan
- Department of Pediatrics, Nationwide Children's Hospital, Columbus, OH, United States
| | - Hanah F Alley
- Department of Neurology, University of Louisville, Louisville, KY, United States
| | - Michael J Eiswerth
- Department of Internal Medicine, University of Louisville, Louisville, KY, United States
| | - Forest W Arnold
- Division of Infectious Diseases, University of Louisville, Louisville, KY, United States
| | - Brock A Martin
- Department of Pathology and Laboratory Medicine, University of Louisville, Louisville, KY, United States
| | - Alaleh E Shandiz
- Department of Pathology and Laboratory Medicine, University of Louisville, Louisville, KY, United States
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Dourra M, Mussad S, Capatina-Rata AM. An Unusual Case of Syphilis With Abdominal Pain. Cureus 2021; 13:e16806. [PMID: 34513412 PMCID: PMC8407414 DOI: 10.7759/cureus.16806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2021] [Indexed: 11/28/2022] Open
Abstract
Syphilis is a multisystem infection caused by Treponema pallidum, a common sexually transmitted bacterium. The different stages and associated signs of syphilis are well characterized. We present an atypical case of syphilis in a 27-year-old female with hepatitis and gastritis. The diagnostic criteria for syphilitic hepatitis and gastritis are discussed here, along with endoscopic and clinical findings, treatment, and a brief literature review.
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Affiliation(s)
- Mohsen Dourra
- College of Human Medicine, Michigan State University, East Lansing, USA
| | - Shiab Mussad
- College of Human Medicine, Michigan State University, East Lansing, USA
| | - Ana M Capatina-Rata
- Internal Medicine, Ascension Providence Hospital - Southfield Campus, Southfield, USA
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A great mimicker of primary biliary cholangitis. Acta Gastroenterol Belg 2021; 84:527. [PMID: 34599585 DOI: 10.51821/84.2.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
A 59 year-old man without past medical history was referred with biochemical features of cholestasis (aspartate aminotransferase (AST) 117 U/L, alanine aminotransferase (ALT) 83 U/L, gamma-glutamyl transferase (GGT) 1307 U/L, alkaline phosphatase (AP) 1803 U/L, total bilirubin 0,7 mg/dL), a strongly positive antimitochondrial M2 antibody (AMA-M2) titer (88 U), weight loss and abdominal pain since several months. He did not take any medications, nor there was a history of alcohol abuse or sexual risk behavior. Upon presentation, clinical examination showed a rather cachectic patient (body mass index 19 kg/m²), without further abnormalities. As primary biliary cholangitis (PBC) was suspected, treatment with ursodeoxycholic acid had been initiated but did not improve the cholestasis nor the pain. Additional investigations didn’t reveal any other irregularities, except for a mildly dilated aortic sinus root of 42 mm. The histopathological findings of a liver biopsy are shown below (Figure 1). This showed granulomas with cholangitis and increased presence of neutrophils, which raised suspicion for an infectious cause.
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